Australasian Anaesthesia 2011 - Australian and New Zealand ...

190 Australasian Anaesthesia 2011Teamwork: hard facts, soft skills. 191with attendance on courses such as the Effective Management of Anaesthetic Crises (EMAC), 9 it’s unclear theextent to which this has impacted on the functioning of the operating room team as a whole. No surgeons areinvolved in EMAC. A crisis management course devised for surgeons from Imperial College, London, has an actorplaying the role of the anaesthetist, with a cardboard cut-out of an anaesthetic machine (personal communication).Stereotypical representation of other professional groups may be inaccurate or even derogatory and can potentiallybe reinforced during single profession team training, for example through consistently simulating negative aspectsof other professions, or through language permitted in single profession discussions (e.g. unhelpful, obstructive,idle). We work in multidisciplinary teams and some of the bigger challenges in teamwork are likely to come frominteractions across these disciplines. Understanding the capabilities of other professional groups, how they processand prioritise information, and the information they need to know to do their job, may be limited in members of theoperating room team. Learning how to negotiate these differences would seem a fundamental requirement fordeveloping teamwork.In order for teams to share information, team leaders need to be open to suggestion. Where a power gradientinhibits team members for speaking up, mistakes will go unchallenged. Bleakely 10 describes the need for democracyin healthcare teams, where all members have a voice. He further describes the “monologic” leader, who does allthe talking and doesn’t invite input. This undemocratic culture provides a further challenge for developing effectiveteams. By way of contrast, the “dialogic” leader, engages in open conversations and encourages suggestions fromthe team members.HARD FACTSMedical error is the third biggest killer, after cancer and heart disease, in North America. 2 Between 6 and 16% ofall hospital admissions are associated with an adverse event, resulting in disability or longer hospital stay. 11-13 It’sbecoming clear that the majority of these medical errors and adverse events are not due to failures in training,medical knowledge or technical proficiency, but to the so-called non-technical factors. Failures in teamwork andcommunication make a substantial contribution. 14-20 Miscommunication both within teams and across teams ismost acute in surgical settings. 21Observational studies in the operating room have identified communication problems. Lingard et al 22 classifiedover 25% of all communications between members of the operating room team as failures, due to poor timing,wrong or incomplete content, or failure to resolve issues. Many of these were observed to result in deleteriouseffects on the efficiency, use of resources and led to delays, procedural errors or tension between team members.BETTER TEAMS HAVE BETTER RESULTSIn a meta-analysis of studies of 2650 non-clinical teams, nearly 20% of the differences in team processes andoutcomes could be accounted for by prior participation of team members in team training. 23 This suggests teamtraining can lead to a change in team behaviour. These improved processes and outcomes also applied to teamswho did or did not regularly work together. A review of published studies on leadership and healthcare teamssupports the proposal that well functioning teams with good leadership can improve patient safety. 24 In a metaanalysisof controlled trials on post-discharge non-pharmacological interventions in patients with heart failure,involving a multidisciplinary team was associated with reduced rates of re-hospitalisation and mortality. 25 There issome evidence that medical team training initiatives exhibit similar effects to those observed in aviation and laboratoryteams. 26 While there are unique factors affecting operating room teams, it seems likely that there will be somesimilarities in the way teams function across different contexts. Indeed in a survey of participants of a simulationbasedcourse in crisis management, anaesthetists reported very specifically the changes they’d made to theirpractice, and the way they managed their team in critical clinical events following the training. 27The WHO Surgical Safety Checklist has, as one of its components, an intention to improve the way the operatingroom staff functions as a team, for example, introduction of team members and sharing of information aboutsignificant patient and case issues. Reports of substantial reductions in post-operative morbidity and mortality arecompelling. 23SOFT SKILLSHowever, teams do not just happen. As in other contexts, collecting a group of highly skilled health practitionerstogether in the operating theatre does not ensure optimal outcomes for every patient. The undeniable evidence onsuboptimal teamwork, and resultant bad outcomes for patients, obliges us to look at some of the soft, non-technicalskills.Based on an extensive review and analysis of the published studies on teamwork across different contexts,Salas 29 identified a number of dimensions that were requirements for a well-functioning team. These are: teamleadership; mutual performance monitoring; backup behaviour; adaptability; and team orientation. Salas proposeda number of underlying conditions that were requirements for teams to be achieve these capabilities: mutual trust;shared mental models; and closed loop communication (Table 1).Table 1. Dimensions required for a well-functioning team [from Salas 29 ]Teamwork Definition Behavioural markersTeam leadershipMutual performancemonitoringBackup behaviourAdaptabilityTeam orientationShared mental modelsMutual trustClosed-loopcommunicationAbility to direct and coordinate theactivities of the other team members,assess team performance, assign tasks,develop team knowledge, skills andabilities, motivate team members, planand organise, and establish a positiveatmosphere.Ability to develop commonunderstanding of the team environmentand apply appropriate strategies toaccurately monitor teammateperformance.Ability to anticipate other team members’needs through accurate knowledgeabout their responsibilities. This includesthe ability to shift workload amongmembers to achieve balance duringperiods of high workload or pressure.Ability to adjust strategies based oninformation gathered from theenvironment including how the team ismanaging the situation. Altering a courseof action or team member task allocationin response to changing conditions(internal or external).Propensity to take other’s behaviour intoaccount during group interactions andthe belief in the importance of the team’sgoal over the individual members’ goal.An organising knowledge structure ofthe relationships among the tasks theteam is engaged in and how the teammembers will interact.The shared belief that team memberswill perform their roles and protect theinterests of their teammates.The exchange of information betweena sender and a receiver irrespective ofthe medium.Facilitate team problem solving.Provide performance expectationsand acceptable interaction patterns.Coordinate individual team membercontributions.Seek and evaluate information thataffects team functioning.Clarify team member roles.Engage in preparatory meetings (briefs)and feedback sessions (debriefs) withthe team.Identify mistakes and lapses in otherteam members’ actions.Provide feedback regarding teammembers’ actions to facilitate selfcorrection.Recognise a workload distributionproblem in their team.Shifting of work responsibilities tounderutilised team members.Completion of tasks by other teammembers.Identify cues that change has occurred,assign meaning to that change anddevelop a new plan to deal with thechange.Identify opportunities for improvement orinnovation for habitual or routinepractices.Remain vigilant to changes in the internaland external environment of the team.Taking into account alternative solutionsprovided by teammates and appraisingthat input to determine what is mostcorrect.Increased task involvement, informationsharing, strategising and participatorygoal setting.Anticipating and predicting each other’sneeds.Identifying changes in the team, tasks,or teammates and implicitly adjustingstrategies as needed.Information sharing.Willingness to admit mistakes andaccept feedback.Following up with team members toensure message was received.Acknowledge that a message wasreceived.Clarifying with the sender of the messagethat the message received is the same asthe intended message.